Cost-sharing mechanisms in health insurance schemes: A ...

Cost-sharing mechanisms in health insurance schemes: A systematic review

Submitted to The Alliance for Health Policy and Systems Research, WHO

From Meng Qingyue, Jia Liying, Yuan Beibei Center for Health Management and Policy, Shandong University

October, 2011

TABLE OF CONTENTS Abstract .............................................................................................................................................. 3 1 Background ..................................................................................................................................... 6 2 Objectives and definitions ............................................................................................................... 7 3 Criteria for inclusion of studies........................................................................................................ 7 4. Methods ........................................................................................................................................ 8

4.1 Searched databases and websites ........................................................................................... 8 4.2 Search strategy ........................................................................................................................ 8 4.3 Review method ...................................................................................................................... 10 5 Results .......................................................................................................................................... 11

5.1 Characters of the included studies ........................................................................................ 11 5.2 Content of cost sharing ......................................................................................................... 14 5.2.1 Distribution of cost-sharing methods in health insurance schemes ..................................... 14 5.2.2 Distribution of cost-sharing methods .................................................................................... 16 5.2.3 Target population covered by cost-sharing methods ............................................................ 16 5.2.4 Services covered by cost sharing methods............................................................................ 18

5.3 Effect of cost sharing............................................................................................................. 19 5.3.1 Effect of the introduction of cost sharing .............................................................................. 19 5.3.1.1 Full fee to cost sharing ................................................................................................... 19 5.3.1.2 Free to cost sharing ........................................................................................................ 20 5.3.1.3 Cost sharing to free ........................................................................................................ 27 5.3.2 Effect of the change of cost sharing methods ....................................................................... 28 5.3.3 Effect of different levels of cost sharing methods ................................................................. 43 6 Discussion ..................................................................................................................................... 52

6.1 Main results in this review .................................................................................................... 52 6.1.1 Improve Health utilization ..................................................................................................... 52 6.1.2 Control Moral hazard ............................................................................................................ 53 6.1.3 Financial risk changes ............................................................................................................ 55

6.2 Significance of this review..................................................................................................... 56 6.3 Limitation of this review........................................................................................................ 57 Acknowledgement ........................................................................................................................... 58 Reference......................................................................................................................................... 59 Annex1 Searching sources, strategies and results ............................................................................ 66 Annex2 screen process and results................................................................................................... 76

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Cost-sharing mechanisms in health insurance schemes: A systematic review Abstract Ab Background Cost sharing in health insurance schemes is a crucial method that would influence both health care utilization and financial burden of the insured population. Effects of cost sharing of health insurance schemes on demand for medical care have been examined in a number of studies. This review is to describe polices and interventions of cost sharing in health insurance schemes; and to describe how the authors have assessed effects of cost sharing methods in health insurance schemes where available. This review focuses on studies about methods of cost sharing applied in health insurance schemes. Health insurance schemes refer to any types of health insurance including public health insurance and private health insurance, country-level health insurance and local level health insurance. Cost sharing methods in this review included copayment, coinsurance and deductible. The mixed methods, including copayment plus coinsurance, copayment plus deductible, coinsurance plus deductible, copayment plus coinsurance and deductible were also included in our review. Studied populations were target population of cost sharing strategies applied in health insurance schemes. In this review, all types of study design (methods) except opinion paper, letter, news, comment, editorial, bibliography, methodological papers, and resource guides were included. Three types of outcome measures were used in this review, including use of health services or drugs, financial risk, and moral hazard. Methods We have searched the published and unpublished literatures about cost sharing methods in health insurance schemes. We have searched the Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews. We searched the following electronic databases: Scopus, PubMed, EMBASE, ScienceDirect, Web of Science, WHOLIS, ELDIS, Global health library, 3ie database of impact evaluations, IBSS, Popline, EconLit, IDEAS, ProQuest, World Health Organization, China National Knowledge Infrastructure, Chinese Medicine Premier (Wanfang Data), OpenSIGLE, NTIS. Related articles also searched by the references of the included studies. We used a pilot stage to test and improve the data extraction form. Relevant information about health insurance schemes, contents of cost sharing methods, and the effects of cost sharing methods were extracted from included documents by two reviewers independently. We firstly described the distribution of all the included studies based on the information we gained via data extraction, which include study location, study time, and study design. Secondly we analyzed the contents of cost sharing policy applied in different countries, which include the health insurance schemes applying different cost sharing methods, the distribution of different cost sharing methods, the target population covered by the cost sharing policy, the health services or drugs used by target population during cost sharing policy. Thirdly we 3

synthesized the key information of cost sharing methods based on the theory framework. Major results A total of 8,057 articles were searched, and 6,904 were left for screening after checking duplications. After screening titles and abstracts, 219 were labelled for retrieval of the full text, of which we were able to obtain 176 full-text documents. Cost sharing methods were used in varied kind of health insurance schemes. In US, employed-sponsored or private health insurance, Medicaid and Medicare all even used copayment in their designation of insurance scheme. Majority of studies in Canada and Australia researched the cost sharing methods used in drug insurance. Studies in Taiwan, Israel, Japan, Belgium, Finland and Germany indicated that their national health insurance tried to introduce or change their copayments/coinsurance. Uganda and India had tested different cost sharing arrangements in their community based health insurance. The categories of cost-sharing methods used by different countries were diverse. Most frequently used method by different health insurance schemes were introduction of copayment and increase the level of copayment, and there were also lots of studies comparing the different copayment levels used by different insurance schemes. Coinsurance, deductible or ceiling and mixed method were less used. The influences of cost sharing methods on utilization of drugs and outpatient services were most frequently studied. The other kinds of health services which were analyzed included diagnostic services, dental services and surgical services, etc. The introduction of cost sharing means a new cost sharing method is implemented no matter it was from free to cost-sharing or full fee to cost-sharing. Totally 74 studies included in this review were to describe a newly cost sharing policy implemented and evaluate its effectiveness. Cost sharing methods were widely used in public health insurance schemes such as National Health Insurance in Taiwan, China; Medicare and Medicaid in US; Germany statutory health insurance; Health insurance in Korea; Medicare in Australia; Public drug health insurance program in Canada, but the effects were different. In this review, 54 included studies described or evaluated the effects of cost sharing by comparing different levels of cost sharing methods applied in health insurance schemes. And most (52) of them were about private health insurance schemes. Discussion One of the purposes of cost sharing is to change the utilization of services or prescription drugs for the enrollee of public or private health insurance schemes. Compared with people in insurance scheme without cost sharing, the introduction of cost sharing decreased the utilization of most kinds of medical services. Different levels of cost sharing could bring different extent of changes in health services utilization. 4

Prescription cost sharing policy seems as a successful tool to control moral hazard both in private health insurance schemes and Medicare. In private health insurance, one of the purposes of cost sharing policy is to control moral hazard by decreasing over consumption of high price drugs and improve the use of generic drugs. The similar result was found in different levels of copayment policy. In public health insurance, the prescription copayment policy is also an effective instrument to control moral hazard. For health policy makers, there are rich materials which could be gained from this systematic review. In this study, we included all kinds of health insurance schemes which practiced cost sharing policy. And according to our analysis, they played different roles to control moral hazard and change financial risk. We synthesize the key information from the included studies based on three categories of cost sharing policy implementation: a new introduction of cost sharing, changes (decrease or increase) of cost sharing levels, different levels of cost sharing methods. These could be matched to different phrases of health policy making.

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Cost-sharing mechanisms in health insurance schemes: A systematic review 1 Background Cost sharing in health insurance schemes is a crucial method that would influence both health care utilization and financial burden of the insured population. The economic purpose of health insurance is to reduce financial risk of illness for the insured. Facing decreasing prices of health care paid by the insured, the insured have incentive to increase their health care utilization due to the price elasticity, even if some health services are not necessary (moral hazard). In health insurance schemes, cost sharing which can take various forms including deductible, co-insurance or co-payment, and ceiling implies higher out-of-pocket payment from the insured for health service. From demand side, the cost sharing mechanism could prevent users from utilization of health care; from the insurance designers’ side, the cost sharing could control the cost of health insurance scheme by correcting the problem of moral hazard. But too high level of cost sharing may make health insurance loose the function of financial protection. Hence the choice about health insurance involves a trade-off between the gains from risk reduction and losses from the incentive to purchase more health care when insured (moral hazard)(Manning and Marquis 1996). Many studies examined the existence of moral hazard by estimating the change of health care demand after change of cost sharing arrangements (Koc 2005). In Manning’s study (1996), an estimate of optimal co-insurance rate of 45% was derived using empirical data at which the marginal gains from increased pooling equals the marginal loss from increased moral hazard. However, due to the complexity of health insurance scheme, including the design of benefit package, premium level, and characteristics of the insured, optimal demand-side cost sharing level may be difficult to find. Effects of cost sharing of health insurance schemes on demand for medical care have been examined in a number of studies. The experimental studies from RAND are the most influential ones in which price elasticity of health services was examined by exploring the differences of health care utilization between participants in health insurances with different cost sharing levels(Newhouse, Manning et al. 1981; Manning, Newhouse et al. 1987). Similar studies could be also found in other countries, for example, in Korea (Kim, Ko et al. 2005). One relevant review was also found, in which evidences about effects of cost sharing on drug prescriptions(Gibson and R 2005) were collected and presented. This review was to determine whether patients responded to increased cost sharing by substituting less expensive alternatives for medications with higher levels of copayments or 6

coinsurance. And this review was not systematic and only focused on association between cost sharing and drug consumptions. Our review will be a systematic scoping review. Results from this review are expected to be helpful for improving health insurance schemes by developing reasonable costing sharing mechanism. In our review, we will include coinsurance, copayment, deductible, ceiling or mixed mechanism used by all types of health insurance schemes.

2 Objectives and definitions The objectives of this review are: 1) To describe polices and interventions of cost sharing in health insurance schemes; and 2) To describe how the authors have assessed effects of cost sharing methods in health insurance schemes where available.

3 Criteria for inclusion of studies This review focus on studies about methods of cost sharing applied in health insurance schemes. Health insurance schemes refer to any types of health insurance including public health insurance and private health insurance, country-level health insurance and local level health insurance. We also include some cost sharing programs such as drug cost sharing program which was implemented under some health insurance schemes. Cost sharing methods in this review included copayment, coinsurance and deductible. The mixed methods, including copayment plus coinsurance, copayment plus deductible, coinsurance plus deductible, copayment plus coinsurance and deductible were also included in our review. Studied populations were target population of cost sharing strategies applied in health insurance schemes. In this review, all types of study design (methods) except opinion paper, letter, news, comment, editorial, bibliography, methodological papers, and resource guides were included. Three types of outcome measures were used in this review. Use of health services or drugs: Number or rate of health service utilization or prescription drugs. This outcome means the trend or changes of the target population consuming health services or drugs because of the implementation or change of cost sharing policy. Financial risk is another outcome measure, which means how the medical burden rose or decreased for the target population after cost sharing implemented or changed, or what is the differences in medical financial burdens between target populations with different levels of cost sharing. 7

Moral hazard means over consumption of health services or drugs. In this review we use control moral hazard as the indicator to evaluate whether the cost sharing realize this aim.

4. Methods 4.1 Searched databases and websites We have searched the published and unpublished literatures about cost sharing methods in health insurance schemes. We have searched the Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews. We searched the following electronic databases:

The Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effectiveness The Cochrane EPOC Specialized Register(and the database of studies awaiting assessment) Cochrane library(CDSR: Cochrane database of systematic reviews; HTA: health

technology Assessment Database; NHS Economic Evaluation Database NHS EED) Scopus PubMed EMBASE ScienceDirect Web of Science WHOLIS ELDIS Global health library 3ie database of impact evaluations IBSS (International Bibliography in Social Science) Popline (Population Information Online) EconLit IDEAS (Research Papers in Economics) ProQuest Dissertation & Theses Database World Health Organization – Publications China National Knowledge Infrastructure (CHKD-CNKI) Chinese Medicine Premier (Wanfang Data)

，

We searched the database which indexed the grey literatures such as: OpenSIGLE (System for Information on Grey Literature in Europe) NTIS (National Technical Information Service) We also searched relative articles based on the references of the included studies.

4.2 Search strategy Search strategies were designed by the topic experts, review group and search experts, after several times of discussion and search pilots in PubMed. The search strategy in PubMed is as follows. 8

#1: “cost sharing” [MH] #2: deductibles and coinsurance [MH] #3: “cost sharing”[TIAB] OR cost-sharing[TIAB] OR OR coinsurance [TIAB] OR co-insurance [TIAB] OR deductibles[TIAB] OR deductible[TIAB] OR copayment [TIAB] OR copayments[TIAB] OR co-payment[TIAB] OR co-payments[TIAB] OR copay[TIAB] OR copays[TIAB] OR co-pay[TIAB] OR co-pays[TIAB] OR ceiling[TIAB] OR ceilings[TIAB] OR “out-of-pocket payment”[TIAB] OR “out-of-pocket payments”[TIAB] OR “out-of-pocket expenditure”[TIAB] OR “out-of-pocket expenditures”[TIAB] OR “OOP”[TIAB] OR “out of pocket payment”[TIAB] OR “out of pocket payments”[TIAB] OR “out of pocket expenditure”[TIAB] OR “out of pocket expenditures”[TIAB] OR “user fee”[TIAB] #4: #1 OR #2 OR #3 #5: "Health Services/utilization"[MH] #6: ("Health Services"[MH] OR "Delivery of Health Care"[MH] OR “health care” [TIAB] OR “health service”[TIAB] OR “health services”[TIAB] OR “preventive service” [TIAB] OR “preventive services” [TIAB] OR “medical care” [TIAB] OR “medical service”[TIAB] OR “medical services”[TIAB] OR ambulatory[TIAB] OR “pathology service” [TIAB] OR “pathology services” [TIAB] OR “pharmaceutical service” [TIAB] OR “pharmaceutical services” [TIAB] OR “chronic service”[TIAB] OR “chronic services”[TIAB] OR “provider service” [TIAB] OR “provider services” [TIAB] OR “physician service” [TIAB] OR “physician services” [TIAB] OR “hospital care” [TIAB] OR drug[TIAB] OR drugs[TIAB] OR prescription [TIAB] OR prescriptions[TIAB] OR medication[TIAB] OR medications[TIAB] OR medicine[TIAB] OR medicines[TIAB] OR healthcare[TIAB]) AND ( use[TIAB] OR utilization[TIAB] OR utilisation[TIAB] OR access[TIAB] OR accessibility[TIAB]) #7: "physician visit"[TIAB] OR "physician visits"[TIAB] OR "outpatient visit"[TIAB] OR "outpatient visits"[TIAB] OR hospitalization[TIAB] OR hospitalized [TIAB] OR hospitalisation[TIAB] OR hospitalised [TIAB] OR "moral hazard"[TIAB] OR "adverse selection"[TIAB] OR "price elasticities"[TIAB] OR "price elasticity"[TIAB] OR overutilization[TIAB] OR overutilizations[TIAB] OR overutilisation[TIAB] OR overutilisations[TIAB] OR over-utilization[TIAB] OR over-utilizations[TIAB] OR over-utilisation[TIAB] OR over-utilisations[TIAB] OR "hospital admission"[TIAB] OR "hospital admissions"[TIAB] #8: “cost of illness”[MH] OR “financial risk”[TIAB] OR “financial risks”[TIAB] OR “financial burden”[TIAB] OR “financial burdens”[TIAB] OR ((cost[TIAB] OR costs[TIAB] OR burden[TIAB] OR burdens[TIAB] OR expense[TIAB] OR expenses[TIAB]) AND (illness[TIAB] OR illnesses[TIAB] OR sickness[TIAB] OR sicknesses[TIAB] OR disease[TIAB] OR diseases[TIAB])) OR “health expenditures”[MH] OR “health expenditure”[TIAB] OR “health expenditures”[TIAB] OR “household expenditure” [TIAB] OR “household expenditures” [TIAB] #9: #5 OR #6 OR #7 OR #8 #10: #4 AND #9 #11: letter[PT] OR news[PT] OR comment[PT] OR editorial[PT] OR bibliography[PT] OR resource guides[PT] 9

#12: #10 NOT #11 We made transferred strategies in other databases or websites according to the characters of them based on the PubMed strategy. The specific searching strategies are attached in annex 1.

4.3 Review method Screening We used a pilot stage to test the screen criteria, in which 20% of searched results were randomly selected and independently assessed by two of the authors, and then reviewers discussed to ensure the same screen approach was being used. In the screen process, each paper identified was screened by the reading titles and abstracts and then the full texts of all the literatures including titles and abstracts were searched. The retrieved full texts were screened and the final included items were identified. The process of screening was done and recorded in the Endnote. The screening process and result in this review was attached in Annex 2. Data extraction Data extraction was done by 3 authors independently. Initially, we also took 20% of the results from the screening process to pilot data extraction form, in which all the articles were double extracted making use of coding form designed in protocol, and then the differences in data extraction form and problems in coding form were identified and discussed by all reviewers and subject experts. After pilot, the coding form was adjusted and improved. Relevant information about health insurance schemes, contents of cost sharing methods, and the effects of cost sharing methods were extracted from included documents. Data analysis We firstly described the distribution of all the included studies based on the information we gained via data extraction, which include study location, study time, and study design. Secondly we analyzed the contents of cost sharing policy applied in different countries, which include the health insurance schemes applying different cost sharing methods, the distribution of different cost sharing methods, the target population covered by the cost sharing policy, the health services or drugs used by target population during cost sharing policy. Thirdly we synthesized the key information of cost sharing methods based on the theory framework as Figure 1. In this review, we analyzed the effect of cost sharing based on the process of health policy making: the introduction of cost sharing; different levels of cost sharing; changes of cost sharing. Three main outcomes were considered: improve health utilization, reduce financial risk, control moral hazard. We listed all the methods of cost sharing used in health insurance programs and how the authors have assessed its effectiveness on outcome indicators if it is available. We presented the outcomes of cost sharing by subgroups such as different types of targeting populations, different health insurance types and different kinds of health services. 10

Reduce financial risk

Full fee

Free charge

Access to health services or drugs

Lower cost sharing Cost sharing

Over consumption of health services or drugs

Higher cost sharing

Control moral hazard

Figure1 Conceptual framework for analysis

5 Results A total of 8057 articles were searched, and 6904 were left for screening after checking duplications. Out of the 6905 articles screened, 123 articles were excluded as they were opinion papers, letters, news, commentary, editorial, or bibliography; 6063 articles were excluded as they were not the studies without descriptions on contents of cost sharing used by health insurance schemes; 141 studies excluded because they were theoretical, methodological studies or work plans, and cost sharing methods in articles have not been implemented; 137 articles excluded because there was no change on the cost sharing methods studied; and 222 studies were excluded as there was no outcomes about health care utilization or financial risks. In addition, 42 documents cannot be judged whether they need to be included or not because full texts of those documents were not retrieved. Finally 176 documents met the inclusion criteria and were used in this review. Annex2 demonstrates the screening process. After screening titles and abstracts, 219 were labelled for retrieval of the full text, of which we were able to obtain 176 full-text documents. Of the 42 we did not obtain, 35 documents were published articles in Journals, and 2 documents were book or book chapters we could not access to. The remaining 5 articles were unpublished reports or thesis and their sources are not clear.

5.1 Characters of the included studies Study sites: Of 176 studies, most of them (114) researched the cost sharing methods used by health insurance in United States, and only about 20 studies are about cost sharing 11

methods used in Middle and Low Income Countries/districts, such as Uganda, India, Israel, Kyrgyzstan and Taiwan, China (Table 1). There is one study comparing cost sharing arrangements of health insurance in Germany and Switzerland. Table 1: Study sites of included studies Country Australia Belgium

Number 4 2

Burkina Faso

1

Canada

14

China Colombia England

1 1 1

Finland France Germany Germany and Switzerland India Israel Italy Japan

1 1 8 1 1 1 1 4

Korea

1

Kyrgyzstan

1

Netherland Rwanda Switzerland

2 2 1

Taiwan, China Uganda United States

8 2 114

Vietnam Zaire

2 1

Study time: We found that about 50% of included studies were done after Year 2000. In US, there are the studies evaluating effects of cost sharing methods since 1960s. And in US the relatively large number of studies in 1970s was due to RAND designing the Health Insurance Experiments at that time period. Table 2: Study time of included studies Country Australia Belgium

Before 1969

1970-1979

1980-1989

1990-1999 1 2

After 2000 3

4

10

Burkina Faso

1

Canada China Colombia England

Finland France Germany Germany and Switzerland

1 1 1

1 1 1

7 1 12

India Israel Italy Japan

1 3

Korea

1

1 1 1

Kyrgyzstan

1


2


4 1 18

2 1

2

28

6

Vietnam Zaire

4 1 60

2 1

Study design: The largest number of studies was retrospective cohort studies, which usually made use of existing databases, found different cohorts with different designs of cost sharing methods, and then observed the differences in health utilization and financial risks between different cohorts. There were also lots of studies applying the design of before and after study to analyze the changes in health utilization and financial risks after change of cost sharing level. Most of controlled trials were studies using trial data from Health Insurance Experiments done by RAND. Table 3: Study design of included studies Country

Controlled trial

Cohort study

Time series study

1

3 2

Canada

3

5

China Colombia England

1

Australia Belgium Burkina Faso

Controlled before and after study

Before and after study

Cross sectional study

4

2

1 1 1

Finland France Germany Germany and Switzerland India Israel Italy Japan

1 3

2

1 3 1

1 1 1

2

Korea

1


Vietnam

1 1 1

Kyrgyzstan


Descriptive study

2 2 1

16

1

1

1

33

14

22

4 2 13

1 15

1

2 13

Zaire

1

5.2 Content of cost sharing 5.2.1 Distribution of cost-sharing methods in health insurance schemes The cost sharing method most frequently researched by existing studies is copayment. In US, employed-sponsored or private health insurance, Medicaid and Medicare all even used copayment in their designation of insurance scheme. For example, a kind of employed-sponsored health insurance (The Kaiser Permanent Medical Care Program) in Northern California US introduced copayment $25-$35 for emergency department services, and Selby’s study evaluated the effects of this copayment on the number of emergency visits(Selby, Fireman et al. 1996). Several studies evaluating cost sharing methods in US mentioned managed care originations or preferred provider organization, but didn’t explicitly described the name and nature of these insurance schemes. Majority of studies in Canada and Australia researched the cost sharing methods used in drug insurance. Studies in Taiwan, Israel, Japan, Belgium, Finland and Germany indicated that their national health insurance tried to introduce or change their copayments/coinsurance. We also found that two developing countries (Uganda and India) had tested different cost sharing arrangements in their community based health insurance. For example, the community based health insurance in Kabarole district of Uganda introduced copayment between 50 to 500 shillings (US$0.05-0.5) for one outpatient consultation, and the Kipp’s study found a decrease in overall outpatients’ visits(Kipp, Kamugisha et al. 2001). Table 4: Distribution of cost-sharing methods in health insurance schemes Country Australia

Belgium Burkina Faso Canada

China Colombia

Health insurance

Copayment

Drug insurance (3) Public health insurance (1) Compulsory health insurance (2) Community based health insurance (1) Drug insurance (12)

3

Not clear (2) Community based health insurance (1) Contributive insurance, subsidized insurance and special

1 1

Coinsurance

Cost sharing methods Deductible or ceiling

Mixed

1 1

Copayment+coinsurance+ceiling(1)

1 3

1

Copayment+deductible(1) Copayment+deductible+ceiling(1) Copayment+coinsurance+deductible(2) Copayment+coinsurance(1) Coinsurance+deductible(1) Coinsurance+ceiling(2) Coinsurance+ceiling(1)

1

14

England Finland France Germany Germany and Switerland India Israel Italy Japan Korea Krygyzsta Netherland Rwanda Switzerland Taiwan,Chi na Uganda USA

Vietnam Zaire

insurance pools(1) National health system (1) National health insurance (1) Complementary health insurance (1) Compulsory health insurance (8) Compulsory health insurance (1) Community based health insurance (1) National health insurance (1) Drug health insurance (1) Employee health insurance (4) National health insurance (1) Not clear (1) Private health insurance (2) Micro health insurance (2) Basic health insurance(1) National health insurance (8) Community based health insurance (1) Not clear (1) Medicaid(13) Medicare(20)

1 1 1 5

2

Copayment+deductible(1)

1 1 1 1 1

3

1 1 2 2 Copayment+deductible(1) 7

Copayment+ceiling(1)

1 1 12 14

Employee or private health insurance (37)

23

Managed care organizations (10) Preferred provider organization (4) Other kinds of health insurance (7) Not clear (23)

9 2

1

4

1

5 10

2

Copayment+ceiling(1) Copayment+coinsurance(1) Copayment+coinsurance+ceiling(1) Copayment +deductible(1) Copayment+coinsurance(6) Copayment+coinsurance+deductible(1) Copayment+deductible(2) Coinsurance+deductible(1) Coinsurance+deductible(1) Coinsurance+deductible(1)

1 7

Copayment+coinsurance+deductible(1) Copayment+coinsurance+deductible(1) Copayment +deductible(1) Copayment+coinsurance (3) Coinsurance+deductible(1)

Social health 2 insurance (2) Community based 1 health insurance (1) Note: the number in bracket means the number of the included studies 15

5.2.2 Distribution of cost-sharing methods As Table 5 shows, the categories of cost-sharing methods used by different countries were diverse. Most frequently used method by different health insurance schemes were introduction of copayment and increase the level of copayment, and there were also lots of studies comparing the different copayment levels used by different insurance schemes. Few studies in Canada and US researched the effects of deductible or ceiling on the health services utilization. For example, to decrease nonessential outpatient visits and encourage a referral system, national health insurance in Taiwan increased the outpatient copayments in different kinds of health institutions except physician clinics(Chen, Schafheutle et al. 2009). Stein’s study investigated the effects of cost sharing on health utilization by comparing the 41 different health benefit plans with different copayment copayments in Columbia district of US(Stein and Zhang 2003). Table 5: Distribution of cost-sharing methods used by country levels Cost-sharing methods

Free to

Introduction To free

Copayment

Canada(4) Israel(1) Germany(4) Kyrgyzstan(1) Taiwan China(6) Uganda(1) US(17)

Coinsurance

US(3)

Deductible or ceiling

Canada(2) Germany(1)

Mixed

Canada(4) Switzerland(1) US(2)

France(1) Uganda(1) US(1)

Full fee to cost sharing Rwanda(2) Vietnam(2) Zaire(1)

Change Decrease Increase

Compare Free with cost Different cost sharing sharing levels

Finland(1) US(3)

Australia(3) Canada(1) England(1) Germany(1) Italy(1) Korea(1) Taiwan China(2) US(20)

Germany and Switzerland(1) India(1) US(9)

Canada(3) Japan(1) US(30)

Belgium(1) Canada(1) Japan(2) US(1)

US(2)

Japan(1) US(5)

Germany(1) US(1)

Australia(1) Netherland(2) US(5) Canada(1) Colombia(1) Germany(1) US(11)

China(1)

Burkina Faso(1)

US(1)

Belgium(1) Canada(1) US(4)

US(5)

5.2.3 Target population covered by cost-sharing methods In Table 6, we grouped studies based on the populations influenced by the cost sharing methods. The cost sharing methods used by health insurance were not applied to only one kind of populations, but the academic studies usually only focused on the effects of cost sharing on one specific kind of populations. Employee, the poor and population with chronic disease were population most frequently researched by 16

studies evaluating cost sharing methods in US. The studies in the countries/districts with national or compulsory health insurance, like Finland, Taiwan, Israel and Germany, were less likely to examine the influences of cost sharing change on a specific kind of populations. Roblin’s study evaluated the impacts of copayments’ increase used by different US’s managed care organizations on adults with type 2 diabetes(Roblin, Platt et al. 2005). A study in Taiwan evaluated the introduction of copayments on drug prescription, and this copayment policy was applied to 98% of the population in Taiwan(Deborah A. Taira 2006). Table 6: Target population covered by cost-sharing methods Target Population The poor Chronic disease The elderly

Children Employee Adults Non-aged General population

Other kinds Not clear

Copayment France(1) US(11) Germany(1) US(12) Canada(2) Taiwan(3) US(9) US(4) Japan(1) US(15) Korea(1) US(5) Australia(3) Canada(2) England(1) Finland(1) Germany(4) Germany and Switzerland(1) Israel(1) Italy(1) Rwanda(2) Taiwan China(4) Uganda(2) US(1) Vietnam(2) Zaire(1) India(1) US(3) Kyrgyzstan(1) US(15)

Coinsurance

Deductible or ceiling

Mixed US(2)

Japan(1) US(1)

US(1) Belgium(1) Japan(1)

US(4) Australia(1) Canada(1) US(1) US(3)

Canada(7) US(4) US(2) US(5) US(1)

US(3) Japan(1) US(1)

US(1) Germany(2) Netherland(2)

China(1) US(3)

US(1) Belgium(1) Burkina Faso(1) Colombia(1) Germany(1) Switzerland( 1) Taiwan China(1)

Canada(2) US(2)

US(4)

17

5.2.4 Services covered by cost sharing methods Table 7 shows how many different kinds health services were influenced by cost sharing methods. The influences of cost sharing methods on utilization of drugs and outpatient services were most frequently studied. In not a few studies, the cost sharing methods were not applied to a specific kind of health services, but a comprehensive range of health services. The other kinds of health services which were not listed on the table included diagnostic services, dental services and surgical services, etc. Studies of Sedjo, Gibson and Esposito all researched how private health insurance in US made use of copayment to influence the statin prescription(Sedjo and Cox 2008) (Gibson, Mark et al. 2006) (Esposito 2003). Israel’ national health insurance introduced different level copayments for outpatients in different levels of health institutions in 1998, and Vardy observed the decreases in outpatients visits in each level of health institutions by a simply before and after study design(Vardy, Freud et al. 2006). Table 7: Services covered by cost sharing methods Services Outpatient visits

Inpatient

Emergency Drugs

Mental services Prevention Comprehensive range of health services

Other kinds Not clear

Copayment Canada(1) Israel(1) Germany(4) Germany and Switzerland(1) Korea(1) Rwanda(1) Taiwan China(2) Uganda(2) US(8) India(1) Kyrgyzstan(1) US(2) Zaire(1) US(7) Australia(3) Canada(4) England(1) Finland(1) Germany(1) Italy(1) Taiwan China(3) US(43) US(5) US(3) France(1) Rwanda(1) Taiwan China(2) US(11) Vietnam(2) US(5) Japan(1)

Coinsurance Belgium(1) Japan(1) US(1)

Japan(1)

Deductible or ceiling Germany(1)

Mixed Belgium(1) Germany(1) Switzerland(1) US(5)

US(2)

US(2)

US(2)

Canada(1) US(1) Canada(9) US(6)

Canada(1) US(1)

US(1) China(1) Japan(1) US(5)

Australia(1) Netherland(2) US(1)

US(1)

US(2) Germany(1) US(1)

US(1) US(2) Burkina Faso (1) Colombia(1) Taiwan China(1) US(5) US(4) US(1) 18

5.3 Effect of cost sharing According to the theory framework, we classify the included studies into three types, and synthesize them: effect of the introduction of cost sharing, effect of changes of cost sharing level and effect of different levels of cost sharing.

5.3.1 Effect of the introduction of cost sharing The introduction of cost sharing means a new cost sharing method is implemented no matter it was from free to cost-sharing or full fee to cost-sharing. Free to cost-sharing means health insurance schemes originally covered all the costs of health services or drugs for their target population, and then the population had to pay some medical costs for their consumption of health services or drugs after the implementation of cost sharing. Full fee to cost-sharing means the target populations originally had to pay all the cost of health services or drugs out of pocket before introducing the cost sharing scheme, which always happened when a health insurance scheme was implemented or some policy changes happened in a health insurance scheme. Totally 74 studies included in this review were to describe a newly cost sharing policy implemented and evaluate its effectiveness. 5.3.1.1 Full fee to cost sharing New Cooperate Medical Scheme (NCMS) in China New Cooperate Medical Scheme(NCMS) in rural China, as a kind of community based health insurance and a cost sharing scheme was implemented in 2005, in which the beneficiaries needed to pay 20% of hospital outpatient cost and 20-80% of inpatient, up to a ceiling of 10 000 Yuan per person per year. This cost sharing policy reduced financial risk of the beneficiaries: catastrophic out of pocket payments of the intervention group decreased from 8.98% to 8.25% after reimbursements, and catastrophic severity for households remaining in catastrophe after reimbursement dropped by 18.7% to an average of 6.34 times the household’s CTP(Sun, Sukhan et al. 2009). Bwamanda hospital insurance scheme, Zaire Bwamanda hospital insurance scheme is a voluntary, community-based health insurance, with a 20% copayment for hospital admission. A retrospective study conducted by Criel (Criel, Van der Stuyft et al. 1999) showed that hospital admission rate of the insured (49%) is nearly 3 times higher than the non-insured (17%), 10 timers higher for surgery, and 7 times for maternity. A formal social insurance scheme in Vietnam Official co-payment by the insured patients is 20% in the social health insurance in Vietnam. This cost sharing policy reduced the financial risk of the insured by 16% 19

and 18%, and this reduction in expenditure is more pronounced for individuals with lower incomes. For the individuals with the mean income, the effect of health insurance was to reduce health expenditures between 28 and 35% (Jowett, Contoyannis et al. 2003; Ardeshir, Sisira et al. 2006). Micro-health insurance (MHI) schemes in Rwanda Insured patients pay a RWF 100 (US$ 0.30) co-payment per episode of illness in health centres; and user fees still existed for those not covered by MHI. User-fee paying individuals reported significantly lower visit rates than the insured. This means financial risk of the insured was reduced(Pia and Kara 2006). Those with MHI coverage were significantly more likely to use health services than the non-insured when getting illness(Saksena, Antunes et al. 2011). 5.3.1.2 Free to cost sharing In the included studies, some health insurance schemes which included NHI, Medicare, Medicaid, Group Health, managed care, private health insurance, drug insurance, High deductible health plans introduced a cost sharing method. Most of the authors analyzed the effect of these cost sharing methods by comparing them with pre-policy situations or with other health insurance schemes which didn’t introduced cost sharing methods. National health insurance (NHI) in Taiwan, China Shuen-Zen Liu (Liu and Romeis 2003; Liu and Romeis 2004) assessed the effects of 1999 NHI’s outpatient prescription drug cost-sharing program for the elderly in Taiwan, China. People with low incomes (earning less than 60% of average personal consumption level in the community), emergency visits, major illness (eg, renal failure), preventive care, and people with extended prescriptions for chronic diseases were exempted from the cost-sharing program. The researchers found that after cost sharing being introduced: For the use of prescription, compared with the non cost-sharing group, the increase rates of total number of prescriptions, number of patients in cost sharing group were 16.87% and 9% smaller; For the financial risk, average prescription cost increase rate was lower (22.05% to 7.78%) in the cost sharing group; for the elderly with chronic diseases, there was a significant increase in drug costs (from 88.06% to 91.46%) above the upper bound of the cost-sharing schedule which was induced by physicians who seemed to prescribe more expensive drugs and extend prescription duration, especially when drug costs exceed the upper bound of the cost-sharing schedule. For the moral hazard, the elderly with non-chronic diseases in the cost-sharing group decreased (1.79%) the use of essential drugs and increased (10.98%) the use of non-essential drugs which means there were some moral hazard happened followed the cost sharing policy In 2005, National Health Insurance implemented a cost sharing policy to control moral hazard, NT$ 50–210 for outpatient, 5–30% for inpatient. The studies (Chen, Liu et al. 2007) showed that neonatal care and free well-baby care increased by less than 1% (from 89.76 and 53.98% in the pre-NHI period to 90.64 and 54.54% in the 20

post-NHI period); utilization of neonatal care had strongly negative significant coefficients for the likelihood of being admitted to the hospital. And this means the cost sharing policy indeed have some effect to control moral hazard. Health insurance in Korea Korea has achieved universal coverage of health insurance since 1989 but the Korean government has raised coinsurance rates several times to control its health insurance expenditures(Kim, Ko et al. 2005) concluded that the cost sharing policy in Korea did not efficiently work. Patient cost sharing in Korea resulted in inequitable medical service utilization and also it did not decrease moral hazard in the sense that the higher cost-sharing sector is less sensitive to cost sharing. Germany statutory health insurance Two cost sharing policies were implemented in Germany, and some authors evaluated the effect of them and got different outcomes.

“

”

Techniker Krankenkasse (TK) launched its deductibles pilot scheme in January 2003. The fixed deductible of €20 per visit caused a reduction of 23.5% in consultations with general practitioners and 42% in consultations with specialists. TK’s total costs for hospital treatment, inpatient prophylactic measures and pharmaceuticals was reduced by 68.4 per participant in the case of the deductible(Claudia and Christian 2006).

€

The German health care reform of 2004 imposed a charge of €10 for the first visit to a doctor in each quarter of the year (the so called “Praxisgebühr”). In Augurzky’s study, the effect was that the cost sharing policy increased use of visit a doctor by 0.003(Augurzky, Bauer et al. 2006). But in Farbmacher and Jochen Schmitt’s study(Farbmacher 2009; Schmitt, Kirch et al. 2009), the outcome was negative. There is a small but significant decrease in the probability of visiting a physician (-0.0419) for the general population in Farbmacher’s study. Jochen Schmitt studied the effects of the policy for the patients with atopic eczema (AE), and the result showed that the target population decreased treated by dermatologists from 52.8 % to 42.3%; the adverse effect was that systemic steroids for AE significantly increased from 5.9 % to 10.3 % by males, from 5.7 % to 8.2 % by females. In Schmitz’s study, the marginal effect of deductible was about zero. Conditional on the health status and risk preferences, holding private insurance with a deductible did not seem to lower the probability of visiting a doctor. Mandatory basic health insurance in Switzerland The Swiss health system reform in 1996 introduced a choice of deductibles for health services in the mandatory basic health insurance. There were variable health insurance deductibles for physician visits: minimal deductible was 150SFr; higher deductibles were 300, 600, 1200, or 1500 SFr. And there was also a copayment of 10% for costs exceeding the deductibles. The study found that primary physician visits decreased for those having higher deductibles than the minimal level for both man and 21

woman(Martin 2001). Medicare in Australia Gool (2006) described the introduction of the ceiling for Medicare beneficiaries in Australia, and the ceiling was about $500 (up from $300) for low and middle income households and $1,000 (up from $700) for others, after which the out of pocket payment of the beneficiaries showed a small and significant fall in 2005. Rand Health Insurance Experiment (HIE) A randomized trial was conducted in 6 sites of USA from 1972 to 1984, it implemented different levels of cost sharing methods for a wide variety of services. 13 included studies used the data from this experiment to analyze the change in the use of different services or medications for different population, and 6 studies analyzed the financial risk outcomes among different cost sharing groups. For health utilization Totally 10 kinds of services or medications utilization were analyzed by the authors, which included medical services, hospitalization, pathology services, outpatient visits, psychotherapy services, dental services, diagnostic/preventive treatment or restorative treatment. Compared with free plan group, most of the health services utilization changes were negative except that hospitalization of population aged ≤15 was 3-5% higher. Different levels of cost sharing also resulted in different extent of changes, for example, prescription size for general populations with 25% coinsurance, 50% coinsurance, PFD, IDP less 2.77, 3.25, 4.80 and 1.78 than free plan respectively. (Table 8) For financial risk Generally, the introduction of cost sharing policy lowered the spending on most of health care services. Anderson found that compared with free care, cost sharing led to a statistically significant 30% decreased in medical charges and a statistically significant 45% decrease in pathology charges(Anderson, Brook et al. 1991). Some authors compared with 95% cost sharing level plan, the per capita expenses in the free plan were 45 percent higher, drug expenditures per person in the free care plan were about 60% higher, the dental expenses were 46% higher(Manning, Bailit et al. 1985; Foxman, Valdez et al. 1987; Manning, Newhouse et al. 1987). For moral hazard Manning (1987) showed that for the poor adults who were with high blood pressure at the beginning of the experiment, there was a clinically significant reduction in blood pressure for those in the free plan compared to those in the plans with cost sharing, and the magnitude of this reduction would lower mortality about 10 percent each year among this group, about 6 percent of the whole population.

Table 8: Utilization changes on cost sharing in Rand health insurance Service or medication

Population

Total Medical services

General

population

Use Changes with free plan 50% less

compare

22

Hospitalization or inpatient service

Pathology services

Outpatient visits

General

ED visits

Antibiotics

Prescription number

Psychotherapy services

Dental services

General

Prosthodontics services

Endodontics &periodontics Diagnostic/preventive treatment or of any restorative treatment

(Newhouse 1984) (Keeler 1992) ≤15 aged (Anderson, Brook et al. 1991) ≤15 aged (Anderson, Brook et al. 1991) General population (Keeler and Rolph 1983) (O'Grady 1985) ≤15 aged (Anderson, Brook et al. 1991) General population (Keeler and Rolph 1983) General population (Manning, Newhouse et al. 1987) General population (Foxman, Valdez et al. 1987) General population (Leibowitz, Manning et al. 1985) Non aged people (Manning, Wells et al. 1986) Non aged people (Manning, Bailit et al. 1985) General population (Manning, Bailit et al. 1985) General population (Manning, Bailit et al. 1985) General population (Manning, Bailit et al. 1985)

26% less

3-5% higher (13% to 3/5%)

；

80% 2/3 because of ED visits decrease 43% less

69%

66% less(95% coinsurance)

80% less; coinsurance)

1/3(95%

-2.77(25%); -3.25(50%); -4.80(PFD); -1.78(IDP) 50% less coinsurance)

(95%

34% less

62% coinsurance)

smaller(95%

1/2 coinsurance)

smaller(95%

1/3 coinsurance)

lower(95%

*means included studies number Medicare is a kind of social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over, and those who are under 65 but are permanently physically disabled or have a congenital physical disability, or those who meet other special criteria. Two studies (Hsu, Price et al. 2006; Trivedi, Rakowski et al. 2008) described the changes in utilization of mammography screen and ED visits for the target population caused by the implementation of copayment policy. These studies found that a $10 copayment lowered screening rates and biennial screening rates by 8.3% and 9.0% respectively, and a $20-50 copayment policy reduced ED visits by 4% compared with those without cost sharing .(Table 9) 23

Table 9: Utilization changes on cost sharing in Medicare Service medication

or Population

Cost method

sharing

Use Changes after cost sharing policy

Mammography screen (Trivedi, Rakowski et al. 2008)

Old women aged 65-69

$10 copayment or 10% coinsurance

8.3% points lower Biennial screening rates; 9.0% points lower Screening rates

ED visits (Hsu, Price et al. 2006)

General population

$20–50 copayments

Decreased 4% (95%CI: 3–6%)

Medicaid is a United States health program for certain people and families with low incomes.

￠

For health utilization and moral hazard A $1 outpatient copayment and 50 prescription copayment decreased the use of outpatient visits and consumption of drugs for the target population. A $1copayment for each of the two outpatient visits in a month caused the declined use, and the price elastic was -0.058(Jay, Jospeh et al. 1978). The study found that the greatest decline happened for the population with chronic diseases(Hopkins, Roemer et al. 1975), but this copayment kept the impoverished people getting the service, for example, overall 12% of AFDC (Aid to families of dependent children), the 15% of blind and disabled, the 20% of chronic diseases in the family said that the prescriptions copayment had kept them getting prescribed drugs; 50 for each of the first two prescriptions in a month decreased prescription utilization rate by 0.03(Nelson, Jr et al. 1984), and it also kept the impoverished people getting the drugs.(Table 10)

￠

We also included two articles about state-level Medicaid program in Oregan (Oregan health plan)(Lowe, McConnell et al. 2006; Lowe 2010) which applied a copayment policy for a variety of services: $2-$20 copayment for outpatient services (physician, vaccine or preventative services, lab and radiology), $2-$15 for prescription drugs, $50 for emergency services, $250 for inpatient services. Compare with non-cost sharing group, the utilization of all covered services reduced (-2.7%, p$20 per 30 days

Change of use of drugs median $10 increase copayment decreased OH ADD use by 9.2%.

Changes of financial risk -

Statin users in employ-based insurance

mean copayment is $15 and mean increase is $1.5 (change:$1.5)

-

statin adherence (Gibson, Mark et al. 2006)

Continually user of statin in employ-based insurance

mean copayment is $12 and mean increase is $6.0 (change:$6)

Adherence (Gibson, Jing et al. 2010)

Patients With Type 2 Diabetes in employ-based insurance Enrollees with chronic disease employees and dependents with chronic

Copayment increased from $10 to $20 to $30 (change: $10)

A $10 index copayment increase was associated with a 3% decrease in the odds of adherence A $10 increase in statin cost sharing was associated with 11.9% decrease in the odds of adherent for continuing users. $10 increased copayment, 4.2%-4.9% adherence decreased

-

Enrollees Diabetic

Copayment from tie1 $10, tie2 $20, tie3 $30 to unique $10;

reduces choosing by as little as 0.4% to 4.5% from 1.86% (p=0.134) points for inhaled corticosteroids to approximately 4% (p=65 enrolled in Public drug insurance plan in Canada (Dormuth, Glynn et al. 2006)

Copayment: Can $10 or Can $25 per prescription up to an annual ceiling of Can $200 or Can $275, depending on annual family income Deductible and ceiling: a deductible of 0%, 1%, or 2% of their annual income, after which they paid 25% of prescription costs until reaching an annual ceiling of 1.25%, 2%, or3% of their income

；

；

；

41

Predictors of Ceasing Inhaled Steroids, Patients covered by the copayment policy were 47% (95% CI, 40%-55%) more likely to cease using inhaled steroids, Patients covered by the coinsurance plus deductible policy were 21% (95% CI, 15%-29%) . Prescription drugs

people over 65 years old enrolled in British Columbia Pharmacare insurance(drug) (Dormuth, Maclure et al. 2008)

From copayment to deductible and coinsurance: From $25 per prescription to a deductible for family of 0-2%, 25% coinsurance for >2% deductible, a ceiling of 1.25%, 2%,3% of income.

emergency CAE admissions increased significantly in the policy intervention group; physician visits has an increase of 3% both in copayment period and IBD period.

-

42

5.3.3 Effect of different levels of cost sharing methods Generally the different levels of cost sharing will be used for the same health services or medications to different population based on their income or health status, and the health insurance benefit package usually include different cost sharing levels for different health services; drug benefit programs always make different levels of cost sharing for different tiers. In this review, 54 included studies described or evaluated the effects of cost sharing by comparing different levels of cost sharing methods applied in health insurance schemes. For outpatient and inpatient services Only 5 articles analyzed how the different levels of cost sharing affect the utilization in private health insurance schemes. Moderate and high cost sharing reduced the use of outpatient service, care seeking, inpatient treatment and primary care. (Table 19) For example, in 21 employer health insurance groups of 45 states and the District of Columbia US(Stein and Zhang 2003), the receipt of any outpatient special substance abuse treatment was 22% and 38% less in the middle and high cost sharing for the enrolled adult compared with those in low cost sharing groups. Table 19: use changes of health service in different level cost sharing policy Health services

population

Cost sharing method 10-50% of the billed amount, or $0-25 per session for outpatient

Change of health utilization

Receipt and number of outpatient specialty substance abuse treatment (Stein and Zhang 2003) Disease-modifying therapy (DMT) for multiple sclerosis (MS) (Avi and William 2010) anti-hypertensive treatment (Yang, Kahler et al. 2011)

18 years and older enrolled in 41 benefit plans

Enrollees in a private health insurance

low copayment(≤50%), high copayment(≥50%))

hypertension patients receiving SPC therapy enrolled in a commercial health insurance

low: $5, medium: $5–30, high: >$30 for $60 for ≥90-day supply

Elderly in Ontario drug program in,

Mean charges ranged from $0 to $26.62

For care of serious symptoms: the high-copay group was less likely (OR=0.22, P=.0001) to seek care than the no-copay group, but the low- and no-copay groups did not differ (OR=0.80, P=.15). persistence to therapies: Analyses of 381,661 patients found significantly lower 3-month and 6-month persistence to therapies with high copayments; Medication use: Relative to high-copayment drugs, risk-adjusted odds ratios at 3 months were 1.29 (95% [CI]: 1.26, 1.32) and 1.27 (95% CI: 1.24, 1.30) for low- and medium-copayment medications, respectively. For general seniors: drug charges had virtually no effect on the number of physician visits. For social assistance

Physicians’ Visits (Grootendorst and Levine 2002)

Compare with low cost sharing: Receipt 22% and 38% less in moderate and high cost-sharing Used number were fewer(P